CQI ISSUES Applying the Trauma Triage Guidelines

CONCERNS ABOUT TRAUMA TRIAGE tCase 1 –Driver of pick-up truck, apparently fell asleep and rolled vehicle into ditch off of a county side road. Truck was found upside down with patient lying on the roof. Windshield is smashed –Patient presents conscious, alert and oriented complaining of lumbar pain. No obvious trauma to head neck chest or abdomen. –Vital signs in normal range.

t Patient is fully immobilized and transported to the closest ED. t Patient in ED becomes confused, difficult to rouse. t ED staff believes that patient should have been transported to the Trauma Centre based on Provincial Guidelines.

CONCERNS ABOUT TRAUMA TRIAGE tCase 2 –Pediatric patient struck by car traveling possibly 50 km/hr. –The patient went up onto the hood of the car, stuck and broke the windshield, and then fell to the road, landing on her back. –The patient did not lose consciousness and was able to get up and ambulate into an nearby restaurant.

t Patient has a laceration to her forehead and is complaining of minor neck and shoulder pain. There were no other significant findings and her vital signs were in the normal range for a 12-year- old. t She was immobilized and transported to a local ED. Her condition did not change enroute.

t The ED staff felt that the patient met the Provincial trauma triage guidelines and should have been transported to the Trauma Centre, based on the potential for significant injury.

WHAT EXACTLY ARE THE CRITERIA FOR THE TRAUMA TRIAGE GUIDELINES??? Receiving medical staff are not always sure about the criteria involved in the Trauma Triage Guidelines...

TRAUMA TRIAGE GUIDELINES t Anatomic Characteristics: – (Any one of these)  Spinal cord injury with paraplegia or quadriplegia  Penetrating injury to the head, neck, trunk or groin  Amputation above the wrist or ankle

TRAUMA TRIAGE GUIDELINES Physiological Characteristics: t Adult (16 years or older)  GCS < or = 10 or;  If GCS is > 10, any two of the following: Any alteration in level of consciousness Pulse rate 120 Blood pressure < 80 systolic (or absent radial pulse) Respiratory rate 24

tPediatric (< 16 years old) –Pediatric Trauma Score of < or = 8

TRAUMA TRIAGE GUIDELINES And lastly... Incident Characteristics: t Paramedic’s judgment based on mechanism of injury, that a patient has sustained a level of injury requiring lead trauma centre care.

t There are only a few reasons to divert the patient meeting these criteria to the closest hospital and they could include the following: Complete airway obstruction in any trauma patient, or the absence of spontaneous respirations or palpable carotid pulse in a blunt trauma patient. TRAUMA TRIAGE GUIDELINES – Notes:

t If the patient meets the Trauma Triage Guidelines and is being transported directly to the Lead Trauma Hospital, … update the facility on the patient’s condition. The receiving facility may then issue a Trauma Team Pre-Alert, based on ED practices and policies. TRAUMA TRIAGE GUIDELINES – Notes:

t For trauma patients going to Hamilton, the Hamilton General Hospital is the Lead Trauma Hospital for adult trauma (> or = 16 years) and all pregnant trauma patients, and the McMaster University Medical Centre is the Lead Trauma Hospital for pediatric trauma patients (< 16 years). TRAUMA TRIAGE GUIDELINES – Notes:

t If the closest Lead Trauma Hospital is greater than 30-minutes from patient assessment, then the patient should be transported to the closest hospital emergency department (unless directed otherwise by the BHP) and the local CACC should be notified to allow dispatch of the Air Ambulance.

TRAUMA TRIAGE GUIDELINES – Notes: t Air ambulances, along with landing and attending at a scene, can respond to a local community hospital for a Modified Scene Response to facilitate rapid transport to the trauma centre. t The patient’s transport should not be delayed waiting for the Air Ambulance.

AIR AMBULANCE UTILIZATION tAir ambulance may be utilized for trauma patients meeting the TTG and for acute medical calls meeting the operational guidelines –Acute medical would include: acute abdomen, acute headache (decreased LOC), acute respiratory failure, chest pain, overdose/poisoning, resuscitated from respiratory or cardiac arrest, status epilepticus, and unstable airway

AIR AMBULANCE UTILIZATION Operational Guidelines t Land Ambulance response > 30 minutes to reach the scene and the air ambulance can reach the scene quicker. t Land Ambulance transport time > 30 minutes to travel from the scene to the Closest Appropriate Hospital

AIR AMBULANCE UTILIZATION Operational Guidelines (con’t) t There are multiple patients who meet clinical criteria and the land ambulance resources are overtaxed. t Judgment - EMS Responders may call based on current situations even if it doesn’t meet operational and/or clinical guidelines.

Saved Time = Saved Lives tMaking the determination –bypassing closer hospitals to transport to a Trauma Centre, or –arranging for a modified scene response saves hours of time spent arranging a transfer, and potentially saves lives.

It’s Raining, It’s Snowing... tWhen appropriate, call for the helicopter regardless of the weather of time of day. tLet them decide if they can come. –If we start appropriately calling for air 100 times a year, then they may need to put another helicopter in our area 1. Really cool 2. A great opportunity for the paramedics in our area).

THE GRAY AREA tTrauma Calls occurring in and around Hamilton –Unclear if Hamilton General is closest available hospital or if TTG followed and Trauma Centre requested –Please indicate on your ACR ‘MEETS TRAUMA TRIAGE GUIDELINES’ Indicates that we know what we’re doing

Trauma Isn’t Everything Other CQI Issues

CHART REVIEW ISSUES CODES It has been over one year since the introduction of the new ACR, and we are still finding significant errors in coding medical and trauma complaints. This causes significant delays in data entry and difficulties in report generation. Please try to use the correct codes

CHART REVIEW ISSUES MISSING FORMS We appear to be not receiving yellow copies of all ACRs, and some of the ACRs that we have returned to medics are not returned to us. We recognize that this may well be a system problem in how the forms are submitted, and we are looking at solutions.

CHART REVIEW ISSUES We have run numbers of some of the missing forms and are tracing these back. Please help these forms find there way home

And Finally… Research Issues TOR STUDY We finished collecting data for the TOR study at the end of January, Congratulations to all of those who assisted us by completing and submitting the paperwork. t This will the first ever validation trial of a clinical guideline for prehospital care! This will lead to significant change in the way primary care paramedics manage cardiac arrest in the future.

And Finally… Research Issues CTAS STUDY We are finally ready to begin collecting data in the CTAS study. If you see some of your fellow paramedics riding out with a clipboard in hand… Another important research project to lead our own profession.

Questions??